CE and PRICE

Course Description:
Acceptance and Commitment Therapy (ACT) is an empirically validated psychological intervention that uses acceptance and mindfulness strategies mixed in different ways with commitment and cognitive-behavioral psychotherapy. ACT was originally created by Dr. Steven C. Hayes. The research and theory behind ACT are reviewed in this online course.

Acceptance and Commitment Therapy (ACT) was first developed in
the late 1980s by Steven Hayes, currently professor of Psychology, University of
Nevada, Reno. Early in his professional career, Hayes was plagued by panic
attacks, especially in professional situations requiring him to speak in front
of his peers or students. He tried Cognitive Behavioral Therapy along with a
number of other self-help strategies, including Eastern meditation and EST.
Three years of CBT led Hayes to the realization that, for him, processing his
thoughts and feelings cognitively actually made them worse. He realized that he
turned his painful fears into suffering whenever he tried various strategies to
get rid of them. Then, in Hayes words,

“Something in that mixture of Eastern thinking and the human potential
movement clicked for me. It was goofy.....But what I saw in what they did, in
there, was the possibility of really pursuing this acceptance side.” Cloud J
(2006) The Third Wave of Therapy. Time Magazine, Feb
13.

What Hayes had learned was that by relating to his panic attacks with
acceptance, he created a space between himself and the emotions and thoughts of
the attack itself. In this space he could choose to act differently. He didn’t
have to let his panic determine his behavior. Thus what is called the “Third
Wave” of Behavioral Therapy was born.

The Third Wave of Behavioral Therapy

The initial period of Behavioral Therapy emphasized changing behavior alone.
The theory proposed that when behavior was modified, changes in beliefs and
emotions would follow. The “Second Wave” of Behavioral Therapy saw the
introduction of cognition to the process. “Second Wave” therapy emphasized
analyzing beliefs, then consciously changing those that needed changing. CBT
therapists look for the ways in which the client’s thoughts are inaccurate in a
dysfunctional way. The therapist challenges these old inaccurate and problematic
thoughts and beliefs and helps the client replace them with new ones that
accurately reflect the client’s life.

The “Third Wave” takes paradoxical
approach to change. In a strong contrast with CBT, which uses the strategy of
attacking and ultimately changing negative thoughts directly, ACT (along with
other “Third Wave” therapies such as Dialectical Behavioral Therapy (DBT) and
Mindfulness-Based Cognitive Therapy (MBCT)) doesn’t try to control private
experiences (thoughts, feelings, sensations, memories, etc.) “Third Wave”
therapies are characterized more by acceptance and disidentification.
Mindfulness training is the common element in “Third Wave” therapies.

Overview of ACT

ACT has its theoretical grounding in Relational Frame Theory (RFT). RFT takes
the view that much of what we consider to be psychopathology results from
negatively evaluating private events and subsequent internal strategies for
trying to avoid them, both of which are linguistic functions. ACT therapist
Jason Luomo, PhD, a Portland, OR, psychologist, summarizes the RFT/ACT
connection as follows:

“RFT holds that while language has been key in allowing us to dominate the
planet and create amazing levels of wealth and security, it also has a dark
side. Basic properties of language seem to lie behind much of the suffering that
humans experience. ACT, the applied technology resulting from RFT, attempts to
help people circumvent language in those areas of life where it is less helpful,
and strengthen the most useful aspects of language in the domains where it tends
to be most helpful.” Luomo, J. “Acceptance and Copmmitment
Therapy.”

In ACT, the client is taught to just notice, rather than evaluate, thoughts
and emotions, accepting them as they are through the application of mindfulness.

This mindful approach further involves the recognition that thoughts and
emotions are experiences we have as opposed to being what we are. In this
process the client gets in touch with and identifies with the ongoing witness or
knower of experiences. ACT sees this internal witness as a transcendental sense
of self that is always there. ACT describes this shift as one from “self as
content,” in which we identify strongly with the content of our private
experiences, to self as the context in which private experiences happen. For
example a depressed client would make the shift from “I’m depressed.” to “I’m
having the thought that I’m depressed.” The client with the tendency to be self
critical might shift from “I’m a terrible person” to “I’m having the thought
that I’m terrible.” A patient suffering from psychotic delusions might make the
shift from “I am the Queen of Sheba” to “I’m having the thought that I’m the
Queen of Sheba.” Such a client might continue to hear voices but not feel so
compelled to act on them or take them seriously. This disidentification from
thoughts and emotions and identification with the witness then allows more
freedom of choice in relation to internal experiences. From Hayes’s perspective,
taking a disidentified stance and accepting attitude towards negative thoughts
and emotions also paradoxically weakens them.

From the ACT perspective
challenging thoughts and emotions are inevitable parts of human experience. The
ACT theory takes the view that suffering is intensified by trying to avoid
difficult or unpleasant experiences. We get stuck in unhealthy patterns of
avoidance leaving us inflexible in the face of life’s challenging experiences.
This inflexibility leads in turn to an inability to access and act on our own
core values.

As such, ACT combines acceptance and mindfulness skills
with activities to help the client rediscover of their core values and then
commit to changes in behavior that reflect them. Actually just the cultivation
of a willingness to face and feel difficult or unpleasant thoughts and emotions
with acceptance rather than struggling against them ultimately leads to greater
awareness of our deepest values and yearnings. ACT therapists further support
this turning towards core values by employing existential questions such as:
“What do you really want your life to be about?” Other techniques include such
exercises as writing your own epitaph or verbalizing your definition of a good
person. Once core values are identified, clients are helped to identify and
commit to a course of action to actualize them.

The overall goal of ACT
is to choose effective behaviors in accordance with one’s own core values even
in the presence of challenging private (internal thoughts and emotions) events.
For example a client who stays home from work for fear of an impending
confrontation with their boss, learns to be able to go to work even though
fearing confrontation.

The ACT Therapeutic Approach and the Role of
Mindfulness The ACT therapist helps the client develop in six core as follows
areas:

Cognitive diffusion: disidentification from thoughts, feelings other private
experiences. A thought is not what I am but something I have or that happens to
me. Thoughts are just thoughts, not reality.

Acceptance: Allow private experiences to come and go without trying to
influence them.

Contact with the present moment: a “here and now” focus of awareness
accompanied with openness to and interest in whatever is happening

Observing the self: utilizing and identifying with a transcendent,
unchanging, continuous consciousness that witnesses one’s experiences.

Values: opening to what are one’s own deepest values.

Committed action: making goals and plans in accord with those values then
acting to actualize them.

Of these six, the first four are strong
elements of mindfulness practice. Mindfulness has a present moment focus that is
non-judgmental towards all experience including thoughts and emotions. In
mindfulness the practitioner also distinguishes between impermanent thoughts and
emotions and that which knows them. ACT therapists use both metaphors and guided
meditative activities to teach these mindfulness skills to their clients. For a sampling of such approaches see the following:

Two audios by ACT therapist Jason Luomo, PhD. The first is a
generic mindfulness meditation exercise guiding the practitioner to be aware or
the full range of present moment experience without judgment. The second is a
standard ACT guided meditation called “Leaves on the Stream.”

Audio of “Thoughts on a Highway” exercise. Guided
meditation on working with thoughts, emotions and introduction to the observing.
witnessing self.A

Hayes is careful to point out that although mindfulness is most
commonly associated with Buddhism, all religions have practices that cultivate a
non-judgmental relationship to our inner experiences. He is concerned that
mindfulness is put into a Buddhist box when it is found in all traditions.

The metaphor and imagery are also used extensively to teach the
ACT approach to clients. The following illustrate this intriguing, sometimes
playful side of ACT:

Video illustrating an ACT metaphor “Demons on a Boat” from Russ
Harris' book The Happiness Trap.

Video role play presentation of the ACT metaphor “The chessboard” (a
metaphor of the mind and its contents).

Visual imagery: ACT therapist Joseph Ciarrochi, PhD has developed playful
visual images to illustrate ACT principles like the one below. Six sets of such
images can be found on his website.

“Thoughts about life are not equivalent to life: Sometimes
our minds tells us a mouse is a monster.”

Research on ACT

Compared with older therapies like CBT, there is less research completed to
date on ACT. Nonetheless, ACT is already listed as an evidence-based practice
for depression by the American Psychological Association and is under
consideration for similar listing for treatment of substance abuse by the
Substance Abuse and Mental Health Services Administration. Other mental health
issues for which positive research results have published include obsessive
compulsive disorder, generalized anxiety disorder, social anxiety disorder,
post-traumatic stress disorder, borderline personality disorder, psychosis,
chronic pain, and coping with chronic physical diseases like diabetes or
epilepsy.

Most research compares one therapeutic modality to a placebo, a wait list, or
other kinds of control groups. Effective modalities show greater effects than
those demonstrated by the control group. This has been true for ACT as well.
However when effective modalities are tested against one another not so much
difference is usually found. In contrast, ACT has done especially well when
directly compared with other effective therapies. In such head-to-head trials
against other modalities, ACT nearly always does modestly better than the other
modality, no matter what it is.

True/False Comprehension Quiz

Current research suggests that ACT has a statistically higher success rate for treatment of depression than control groups.

TrueFalse

The use of mindfulness-based acceptance strategies is common to both all forms of CBT and ACT.

TrueFalse

RFT, the theoretical basis for ACT, suggests that while language is effective at evaluating and solving external problems, when the same language strategies are applied to challenging emotions or thoughts, suffering is more likely to ensue.

TrueFalse

ACT research shows it to be effective for depression and anxiety disorders but not for psychosis.

TrueFalse

Steven Hayes considers ACT to be a Buddhist form of therapy.

TrueFalse

Steven Hayes, the developer of ACT, suffered from OCD. ACT came from his successfully treating himself.

TrueFalse

ACT is currently considered an evidence-based practice only for depression.